Download Leadership, Cohesion, Morale, and the Mental Simon Wessely, and Neil Greenberg

Psychiatry 75(1) Spring 2012
49
Leadership, Cohesion, Morale, and Mental Health of Armed Forces
Jones et al.
Leadership, Cohesion, Morale, and the Mental
Health of UK Armed Forces in Afghanistan
Norman Jones, Rachel Seddon, Nicola T. Fear, Pete McAllister,
Simon Wessely, and Neil Greenberg
UK Armed Forces (AF) personnel deployed to Afghanistan are frequently exposed
to intense combat and yet little is known about the short-term mental health
consequences of this exposure and the potential mitigating effects of military factors such as cohesion, morale, and leadership. To assess the possible modulating
influence of cohesion, morale, and leadership on post-traumatic stress disorder
(PTSD) symptoms and common mental disorders resulting from combat exposure
among UK AF personnel deployed to Afghanistan, UK AF personnel, during their
deployment to Afghanistan in 2010, completed a self-report survey about aspects
of their current deployment, including perceived levels of cohesion, morale, leadership, combat exposure, and their mental health status. Outcomes were symptoms of common mental disorder and symptoms of PTSD. Combat exposure was
associated with both PTSD symptoms and symptoms of common mental disorder.
Of the 1,431 participants, 17.1% reported caseness levels of common mental
disorder, and 2.7% were classified as probable PTSD cases. Greater self-reported
levels of unit cohesion, morale, and perceived good leadership were all associated
with lower levels of common mental disorder and PTSD. Greater levels of unit cohesion, morale, and good leadership may help to modulate the effects of combat
exposure and the subsequent development of mental health problems among UK
Armed Forces personnel deployed to Afghanistan,
Previous research has examined the
mental health of United Kingdom Armed
Forces (UK AF) personnel both before and
after deployment to Afghanistan (Fear et al.,
2010; Hotopf et al., 2006). However, studies of deployment mental health are largely
based on retrospective accounts of deployment experiences, and there is a paucity of
mental health survey data gathered while
personnel are deployed. Currently, the United
States deploys the Mental Health Advisory
Team (MHAT) to assess the mental health of
personnel during their deployment. The results of these surveys have been used to support a reduction in deployment length from
16 months to 12 months and an increase
in psychological support provision for deployed U.S. forces (Office of the Command
Surgeon, 2009). In 2010, the Academic Centre for Defence Mental Health (ACDMH),
Norman Jones, MSc, Rachel Seddon, MSc, Nicola T. Fear, Ph.D., and Neil Greenberg, M.D., are affiliated with
the Academic Centre for Defence Mental Health, Department of Psychological Medicine, Institute of Psychiatry, at
King’s College in London. Pete McAllister, MSc, and Simon Wessely, M.D., are with the King’s Centre for Military
Health Research, Department of Psychological Medicine, Institute of Psychiatry, at King’s College.
Address correspondence to Norman Jones at the Academic Centre for Defence Mental Health, Weston Education
Centre, 10 Cutcombe Road, London SE5 9RJ, UK. E-mail: [email protected].
© 2012 Guilford Publications, Inc.
50
Leadership, Cohesion, Morale, and Mental Health of Armed Forces
a UK–based military research team, conducted a mental health survey of UK military personnel while they were deployed in
Iraq (the Operational Mental Health Needs
Evaluation – Iraq: OMHNE (I) (Mulligan et
al., 2010), using a similar methodology to
the U.S. MHAT. Results from OMHNE (I)
found low levels of probable PTSD (3.4%)
and a rate of common mental health disorders similar to that found in the UK population (McManus et al., 2009). However, since
the operational environment in Afghanistan
is considerably more dangerous and austere
than was the case in Iraq during OMHNE
(I), repeating the survey in Afghanistan was
thought to be useful.
There is considerable confusion about
how to best implement primary prevention
of mental health disorders for those facing
combat. Is this best achieved, as military
doctrine often states, by promoting group
identity and cohesion, or is it related to delivering specific mental health interventions,
such as pre-deployment stress briefings,
stress inoculation, or, as is being currently
tried in the United States, emotional fitness
training (Mental Stress Training Is Planned
for U.S. Soldiers, 2009)? Previous research
suggests that having a combat role is associated with the development of PTSD (Fear
et al., 2010), however, military factors such
as leadership, morale, and unit cohesion may
help to reduce this risk (Office of the Command Surgeon, 2009; Mulligan et al., 2010).
This paper uses data from a survey of mental health in UK AF personnel deployed to
Afghanistan to examine the relationship between combat exposure, cohesion, morale,
leadership, and measures of mental health.
The OMHNE (A) survey examined the following hypotheses: (1) the levels of both
PTSD symptoms and symptoms of common
mental disorder would be higher for those experiencing greater levels of combat exposure,
and (2) subjectively high levels of perceived
leadership, morale, and cohesion would be
associated with lower levels of both PTSD
symptoms and symptoms of common mental
disorders.
METHODS
The OMHNE (A) visit was conducted
between January 23 and February 26, 2010,
during operation HERRICK 11; HERRICK
is the codename for the current UK operations in Afghanistan. Participants were eligible for the study if they were members of the
Royal Navy (including the Royal Marines),
Army, or the Royal Air Force and were deployed to Afghanistan during the study data
collection period. The target sample size was
1,425 personnel, which represented 15% of
the 9,500 personnel that made up the UK’s
deployed force in Afghanistan at the time of
the survey. The sampling strategy aimed to
include a mixture of personnel deployed to
major base areas and to more austere and
dangerous locations. Although our sampling
strategy was not random, we based it on personnel records obtained from headquarters
staff, in an effort to ensure that the final sample was representative of the whole deployed
force.
Data were collected using a self-report
questionnaire distributed by the OMHNE
(A) survey team. During a location visit, commanders were asked to assemble all available
personnel in one central location to receive
a brief from a member of the survey team
prior to the surveys being distributed. The
briefing explicitly informed potential respondents that completion of the questionnaire
was voluntary. Personnel were assured that
all information was confidential, that their
individual responses would not be passed
on to commanders or medical staff, and that
no individual would be named in any study
report. Respondents were informed that all
personal identification information would
be separated from the questionnaire by the
study team and stored separately. Minimal
information about each respondent’s identity was gathered to avoid any one individual filling out more than one questionnaire.
The questionnaire took approximately 25
minutes to complete. Participants were not
given any payment or any other inducement
Jones et al.
to take part in the study. Once completed,
participants placed their questionnaire in an
envelope and sealed it before giving it to a
member of the study team. The study gained
ethical approval from the Ministry of Defence’s Research Ethics Committee.
The survey tool included questions
about socio-demographic and military characteristics, deployment experiences, unit factors, the homeland environment, and force
health protection factors, such as receiving a
stress brief prior to the deployment and taking a period of rest and recuperation (R&R)
in a location outside the operational theatre.
Psychological health status was assessed using the 12-item General Health Questionnaire (GHQ-12) (Goldberg et al., 1997) using a cut-off score of four or more to identify
“cases” and severity scores of 0, 1, 2, and 3
for each item to generate a continuous measure (range 0 to 36). Symptoms of PTSD were
assessed using the 17-item National Centre
for PTSD Checklist Civilian Version (PCLC) (Weathers et al., 1994). Probable PTSD
caseness was defined using a validated cutoff score of 50 or more, and for the purposes
of examining the effect of the three variables
of interest (morale, leadership, and cohesion)
on PTSD, the PCL scores were treated as a
count variable, ranging from 17 to 85. To
improve model fit, the scores were recoded
to score from 0 to 68. Combat exposure was
assessed with a 17-item measure that asked
about the frequency of exposure to potentially traumatic combat events adapted from the
combat experiences scale (Hoge et al., 2004).
The 5-point rating scale measured increasing
levels of exposure to each of the questionnaire items, from never through once, 2–4
times, 5–9 times, to 10 or more times. This
was also treated as a count variable in the
analysis.
The cohesion items were: “I feel a
sense of comradeship (or closeness) between
myself and other people in my unit,” “I am
able to go to most people in my unit when I
have a personal problem,” and “I feel well
informed about what is going on in my unit.”
Participants were asked to rate their strength
51
of agreement (strongly agree, agree, disagree,
and strongly disagree). The dropped cohesion item was “my seniors are interested in
what I do or think,” which was associated
with leadership rather than cohesion.
Leadership items were: “my seniors
embarrass juniors in front of other unit
members” (reverse scored), “my seniors accept extra duties or tasks for the unit in order
to impress their superiors” (reversed scored),
and “my seniors treat all members of the unit
fairly and show concern about the safety of
unit members.” The items were rated never,
seldom, sometimes, and always.
Morale items were: “morale within
the unit has generally been high,” “the unit
has been motivated and enthusiastic,” “the
unit has been operating efficiently,” and “I
have felt good about being part of this unit.”
Again, participants were asked to indicate
their strength of agreement, ranging from
strongly agree, agree, no strong feelings either way, disagree, to strongly disagree. The
cohesion and leadership measures have been
used in other studies of health in the UK AF
(Fear et al., 2010; Hotopf et al., 2006).
Analysis
Analyses were carried out in STATA
10.1. Statistical significance was defined as p
< 0.05. To allow us to generalize our results
to the whole deployed force, whole force
demographic data at the time of the survey
were confirmed and sample weights were
generated for the following variables: rank,
sex, and reserve or regular engagement status. Sample weights for age and relationship
status were not generated, as comparative
data were not available. The weights were
applied using the svy command in STATA.
The effect of demographic characteristics,
combat exposure, and the three variables
of interest on GHQ12 caseness was examined using unadjusted and adjusted binary
logistic regression analysis, with combat
exposure, morale, leadership, and cohesion
entered into the model as continuous vari-
52
Leadership, Cohesion, Morale, and Mental Health of Armed Forces
TABLE 1. Demographic Characteristics of the OMHNE Sample
Characteristic
Rank
OMHNE Sample
Deployed Force
n (%)
n (%)
Junior
1051 (73.4)
8520 (65.9)
Officers and Senior Ranks
379 (26.5)
4410(34.1)
1430
12930
1308 (91.7)
12090 (93.6)
119 (8.3)
820 (6.4)
1427
12910
Regular
1315 (93.1)
11684 (94.0)
Reserve
98 (6.9)
750 (6.0)
1413
12434
Total
Sex
Male
Female
Total
Regular/Reserve
Total
Age
< 25 years
605 (42.3)
> 25 years
825 (57.7)
Total
1430
Not Available
Relationship
In a Relationship
945 (66.2)
Not in a Relationship
483 (33.8)
Total
1428
Not Available
GHQ12 Caseness
Case
242 (17.1)
Non-case
1174 (82.9)
Total
1416
PCL-C Caseness
Case
Non-case
Total
38 (2.7)
1374 (97.3)
1412
ables. As small numbers of personnel were
classified as PTSD cases, the PCL-C was
analyzed as a continuous variable. Also, as
both the PCL-C and combat exposure scores
were skewed (skewness = 2.148 and 0.973,
respectively), the effect of combat exposure
morale, cohesion, and leadership on PCL-C
scores was examined using unadjusted and
adjusted negative binomial regression with
incidence-response rates (IRRs). We adjusted
for demographic variables in the first model
and combat exposure with the demographic
variables in the second model. To determine
the actual relationship between combat exposure and symptoms of PTSD, the PCL-C
and combat exposure scores were examined
using unweighted data before proceeding to
the full analysis using sample weights. Pearson’s test was used without sample weights
applied to examine the correlations between
the three variables of interest (morale, cohesion, and leadership) prior to adjusting for
them in the various weighted analyses. The
results suggested that cohesion and morale
were correlated (r = 0.58). Morale and leadership were also correlated but at a lower
level (r = 0.42), and cohesion and leadership had the weakest correlation (r = 0.38).
In view of the correlation between cohesion
and morale, we decided not to control for
these variables in the adjusted binomial and
logistic regressions.
379 (26.7)
Often
154 (10.9)
Always
Disagree
Strongly Disagree
47 (3.3)
I have felt good about being part of this unit (n = 1,418)
*Reverse scored
20 (1.4)
10 (0.7)
The unit has been motivated and enthusiastic (n = 1,417)
The unit has been operating efficiently (n = 1,417)
28 (2.0)
Morale within the unit has generally been high (n = 1,419)
81 (5.7)
71 (5.0)
74 (5.2)
97 (6.8)
434 (30.7)
387 (27.3)
401 (28.4)
658 (46.4)
Treat all members of the unit fairly (n = 1,413)
Show concern about the safety of unit members (n = 1,417)
Morale: During THIS DEPLOYMENT:
180 (12.8)
85 (6.0)
*Accept extra duties or tasks for the unit in order to impress their superiors
(n = 1,411)
95 (6.7)
20 (1.4)
*Embarrass juniors in front of other unit members (n = 1,416)
Leadership: During THIS DEPLOYMENT my Commanders do the following:
I feel well informed about what is going on in my unit (n = 1,417)
291 (20.6)
77 (5.4)
My seniors are interested in what I do or think (n = 1,414)
349 (24.6)
68 (4.8)
I am able to go to most people in my unit when I have a personal problem
(n = 1,417)
94 (6.6)
Disagree
14 (1.0)
Strongly Disagree
I feel a sense of comradeship (or closeness) between myself and other
people in my unit (n = 1,415)
Unit Cohesion: During THIS DEPLOYMENT:
Deployment Unit Attribute (n)
TABLE 2. Cohesion, Leadership and Morale: Itemized Responses
324 (22.8)
200 (14.1)
326 (23.0)
298 (21.0)
No Strong Feelings
Either Way
249 (17.6)
326 (23.1)
400 (28.3)
348 (24.6)
Sometimes
694 (49.0)
823 (58.2)
716 (50.5)
765 (54.1)
Agree
Response n (%)
596 (42.0)
779 (55.0)
746 (52.6)
715 (50.4)
Agree
82 (5.8)
157 (11.1)
283 (20.1)
309 (21.8)
Seldom
190 (13.4)
223 (15.8)
284 (20.0)
542 (38.3)
Strongly Agree
370 (26.1)
357 (25.2)
251 (17.7)
281 (19.8)
Strongly Agree
41 (2.9)
95 (6.7)
463 (32.8)
644 (45.5)
Never
Jones et al.
53
54
Leadership, Cohesion, Morale, and Mental Health of Armed Forces
TABLE 3. The Effect of Leadership, Morale, and Cohesion on GHQ12 Caseness, Unadjusted and Adjusted
Odds Ratios (OR and AOR), with 95% Confidence Intervals (95% CI)
Factor (n)
OR (95% CI)
1
AOR (95% CI)
2
AOR (95% CI)
Leadership (n = 1,370)
0.85 (0.82–0.89)
0.85 (0.81–0.89)
0.86 (0.82–0.90)
Morale (n = 1,377)
0.77 (0.73–0.81)
0.78 (0.74–0.82)
0.78 (0.75–0.83)
Cohesion (n = 1,379)
0.66 (0.6 –0.72)
0.67 (0.61–0.73)
0.67 (0.61–0.74)
Note. 1. Adjusted for Age, Rank, Engagement, Sex, and Relationship Status; 2. Adjusted for Age, Rank, Engagement, Sex,
Relationship Status, and Combat Exposure
RESULTS
The final sample consisted of 1,431
participants, 16.4% of the UK AF personnel
deployed to Afghanistan at the time the survey was conducted. Three personnel refused
to complete the questionnaire and a further
three provided only brief demographic information and left the rest of the questionnaire blank; the final response rate was thus
99.6%. The OMHNE sample contained
greater proportions of junior ranks, females,
and reservists than the deployed force. To
account for this, sample weights were generated and applied. The demographic characteristics of the sample are shown in Table 1.
Looking at the components of leadership in more detail showed that 67.3% of
leaders seldom or never embarrassed their
subordinates, 52.9 % seldom or never accepted extra duties to impress, 59.1% often
or always treated their subordinates fairly,
and 73.7% often or always showed concern
for their subordinates.
Measures of cohesion showed that
92.4% of respondents felt a sense of comradeship with others in their unit, 70.5% felt
that they could go to most people in their
unit if they had a personal problem, 73.8%
felt that their seniors were interested in them
(although this was dropped from the analysis as described in the methodology section
of this paper), and 62.4% reported that they
were well informed about what was going on
in the unit.
For morale, 70.2% of respondents reported morale in their unit as being generally
high, 70.3% reported that motivation and
enthusiasm were high, 80.2% felt that their
unit was operating efficiently, and 68.1%
felt good about being part of their unit. The
itemized responses to the three domains are
shown in Table 2.
The analysis of the effect of combat
exposure on PCL-C scores suggested that
higher levels of combat exposure were associated with raised levels of PTSD symptoms
(IRR 1.013 95% CI 1.012–1.015).
A total of 17.1% (n = 242) of the
unweighted OMHNE sample (n = 1,416)
reported symptoms of common mental disorders at caseness levels, as measured by
the GHQ12. Table 2 shows the association
of leadership, morale, and cohesion with
GHQ12. Higher levels of cohesion, morale,
and leadership are associated with lower levels of GHQ caseness, with cohesion having
the greatest effect, followed by morale and
then leadership. This effect persisted after
adjusting for sociodemographic characteristics and then combat exposure.
A total of 2.7% (n = 38) of the unweighted OMHNE sample (n = 1,412) reported symptoms of probable PTSD at caseness levels as measured by the PCL-C, with
a cut-off score of 50 or more. Table 3 shows
the associations of leadership, morale, and
cohesion with PCL-C scores. Greater levels
of perceived leadership, morale, and cohesion were associated with lower scores on
the PCL-C. After adjusting for demographic
characteristics and combat exposure, cohesion had the strongest association with PCLC scores followed by leadership and then
morale (see Table 4).
Jones et al.
55
TABLE 4. The Effect of Leadership, Morale, and Cohesion on PCL-C Score, Unadjusted and Adjusted
Incidence-Response Ratios (IRR and Adj IRR) with 95% Confidence Intervals (95% CI)
Factor (n)
IRR (95% CI)
Adj IRR (95% CI)
1
Adj IRR (95% CI)
2
Leadership (n = 1,365)
0.89 (0.88 0.91)
0.90 (0.88–0.92)
0.90 (0.88–0.92)
Morale (n = 1,374)
0.93 (0.90–0.95)
0.93 (0.90–0.95)
0.91 (0.89–0.93)
Cohesion (n = 1,375)
0.89 (0.86–0.93)
0.89 (0.86–0.93)
0.86 (0.82–0.89)
Note. 1. Adjusted for Age, Rank, Engagement, Sex, and Relationship Status; 2. Adjusted for Age, Rank, Engagement, Sex,
Relationship Status, and Combat Exposure
DISCUSSION
In this study of deployed UK military personnel, we found low levels of both
symptoms of PTSD and common mental
disorders, despite exposure to high levels
of combat, serious injury and death (at the
time of writing, there have been 322 deaths
since 2001, the majority of which have been
clustered in recent years, with 108 deaths occurring in 2009, of which 107 were combat
related [Defence Analytical Services and Advice, 2010]). Our study took place in January and February 2010, which continued to
be a very busy operational period for UK
troops. The results of the current study are
consistent with our findings from a previous
survey conducted in Iraq, which also demonstrated low levels of PTSD; however, the level of combat exposure at the time of the Iraq
survey was much lower. The rates of probable PTSD in the current survey are similar
to those reported in our studies of non-deployed personnel (Fear et al., 2010; Hotopf
et al., 2006). It therefore seems that certain
characteristics of either the deployment to
the Afghanistan theatre of operations or the
personnel deployed appear to promote high
levels of resilience in the face of substantial
combat exposure. In the current study, there
was a small but significant relationship between the frequency of combat exposure and
levels of PTSD. However, greater levels of
perceived leadership, morale, and cohesion
were associated with lower levels of self-reported PTSD symptoms, suggesting that they
may have some role to play in mitigating
against the development of PTSD symptoms
or are at least reported by those who have
better mental health.
There are a number of explanations
for the association between subjectively good
cohesion leadership and morale and better
mental health (Updegraff, Silver, & Holman,
2008; Brailey et al., 2007). First, it is possible
that they contribute directly to better mental
health. Good leaders are likely to be generally supportive of their subordinates and
will endeavor to ensure that they feel cared
for and respected. In our study, this was
evidenced by the highest rating of leader behavior being given to “showing concern for
subordinates and not embarrassing juniors
in front of others.” It is likely that positive
leader behaviors, such as encouraging help
seeking for personal problems, may help to
offset the effects of stigmatizing beliefs about
mental health problems that are known to
have a detrimental effect on stress (Gould
et al., 2010). There was some evidence suggesting that this may have been so, as nearly
three-quarters of our respondents reported
that they would seek help from another
person in their unit if they had a personal
problem, which may also reflect the high levels of cohesion reported in this study. Given
that resilience to adversity may be associated
with a positive state of mind, it is possible
that the stress-mitigating effect of all three
military variables was associated with feeling
both physically and emotionally protected
by leaders in the unit and also having trust
in peers and friends. As the study was crosssectional in nature, we could not, however,
show causality, and it may be that personnel
who reported generally good mental health
56
Leadership, Cohesion, Morale, and Mental Health of Armed Forces
were more likely to perceive and report good
leadership cohesion and morale.
In our study, cohesion was most
strongly associated with lower levels of
symptom reporting. Good social support, a
substantial component of cohesion, reportedly reduced the severity of traumatic stress
and depressive symptoms in US veterans (Pietrzak et al., 2009). Unit cohesion may have
influenced mental health directly through the
facilitation of peer support. As previously
stated, substantial numbers of personnel
would seek help from other unit members if
they had a personal or emotional problem.
Further, approximately three-quarters of the
leaders were perceived to act in such a way
as to protect subordinates from embarrassment, which might further reduce potential
barriers to disclosing and solving personal
problems and thereby promote cohesion.
Of course, it is possible that feeling part of
a cohesive unit is a product of better mental health. Whatever the direction of effect,
our data suggest that for good operational
mental health, high levels of perceived cohesion probably also need to be present. Personnel in cohesive units are likely to have
greater confidence in both their leaders and
comrades and as a result may be more effective in combat and in adversity. Historically,
morale has been suggested as an important
component of both operational efficiency
and good mental health in military personnel (Grinker & Spiegel, 1963). In our study,
morale in the units surveyed was good, with
over three-quarters reporting high morale.
Cohesion and morale operate at a group
level, but they impact on the individual and
rely on both leaders and peers fostering
them, whereas leadership is behavior-driven
and modifiable and will undoubtedly impact
on both cohesion and morale. We therefore
suggest that leadership is given the prominence it deserves as a primary driver of good
mental health rather than over-investing in
indirect methods such as stress briefing and
other educational approaches, which in their
current form appear to have limited value in
the UK military (Mulligan et al., 2010).
The key message of this study is that
poor mental health, specifically PTSD, does
not inevitably follow exposure to combat
and that good perceived cohesion, morale,
and leadership will be reported by those
who have better mental health. This is somewhat reassuring as all are directly modifiable through effective leadership training,
personal training, and group-based military
activities. Although mental health disorders
can be treated by deployed mental health
teams (Jones et al., 2010), the promotion
of leadership, morale, and cohesion by unit
commanders appears worthwhile, whereas
strategies such as pre-deployment briefing
(Sharpley et al., 2008) and reactive measures
such as critical incident stress debriefing appear to have little effect (Sijbrandij et al.,
2006). Finally, the data sampling strategy
sought to ensure that a cross-section of all
units deployed in theatre were surveyed, and
as a consequence, we sampled a considerable number of units. In addition, these units
were widely dispersed in various locations,
often in small groups. It was therefore impossible to control for cluster effects, and we
are thus unable to say whether perceptions
of morale, cohesion, and leadership were influenced by unit factors or were related to
the individual’s prevailing state of mind.
Implications
Our results indicate that, in the main,
the psychological health of UK personnel
currently deployed to high intensity combat
operations is robust, with levels of common
mental health problems similar to both the
non-deployed setting and the general population (approximately 17% in the OMHNE
sample compared with approximately 17.6%
in the general and non-deployed population)
(Jenkins et al., 2009). The importance of
leadership, cohesion, and morale are likely
to have equal salience in non-military organizations that require personnel to undertake
arduous duties in challenging environments.
These data suggest that UK Armed Forces
Jones et al.
have correctly placed great emphasis on developing credible leaders through training
and selection, as good perceived leadership
was reported by those with better mental
health. High quality leadership in all units is
a vital piece of the moral component of modern warfare and has effects at an individual
psychological level that go well beyond operational effectiveness. The continued focus
on all three factors both during steady state
and in the period before, during, and after
deployment may help to promote military
effectiveness and reduced sickness absence.
As King (2006) states, “military institutions
depend on a level of social cohesion that is
matched in few other social groups” (King,
2006). Our data also suggest that levels of
perceived high quality leadership, cohesion,
and morale may have an effect on the mental
health of personnel deployed to high tempo
combat operations. At the very least, better
mental health was present when any of the
three elements was endorsed by personnel.
And as previous generations knew, no matter how well led and how high the morale,
in every military conflict some personnel will
inevitably become psychiatric casualties. We
therefore suggest that regardless of how high
the cohesion and morale, and however good
the leadership, the provision of good quality
mental healthcare on deployment is essential
(Lazarus, 1991).
57
er, & Biddle, 2001; Decoufle, Holmgreen, &
Boyle, 1992). Studies that have examined the
influence of anonymity in research studies
with military personnel suggest that reporting bias can occur when using anonymous
and identifiable forms in the same survey
(Fear et al., submitted; McLay et al., 2008).
The OMHNE (A) team did their utmost to
reassure personnel that the information they
provided was confidential; however, fears
about a potential breach of confidentiality
and potential stigmatization may have influenced the participants’ responses. We did not
measure individual psychology in our study
and therefore cannot incorporate this into our
findings. We are thus unable to say whether
having a positive mindset influenced the reporting of leadership, morale, and cohesion.
Finally, because of the way in which the data
sampling strategy was constructed—that is,
to ensure that we included a cross-section
of all units deployed in theatre—we have a
substantial number of units in the sample.
This is further compounded by the fact that
the units were often widely dispersed in a
variety of locations, often in small platoonsized groups. It was therefore not possible to
control for cluster effects in this sample, even
though we feel that this would have been desirable.
CONCLUSION
Study Limitations
While considerable efforts were made
to minimize selection bias and apply sample
weights, the OMHNE (A) data were derived
from a non-random sample of UK AF personnel. Therefore, some caution should be
exercised when generalizing the findings to
all personnel deployed to HERRICK 11 and
other deployments. In common with many
other epidemiological studies, we used selfreport measures which may not have the accuracy of an in-depth clinical interview and
which may have inflated the levels of disorder and symptom reporting (Forbes, Cream-
The results of this study support both
hypotheses: levels of both PTSD symptoms
and symptoms of common mental disorder
were found to be higher for those experiencing greater levels of combat exposure; and
leadership, morale, and cohesion were associated with lower rates of both PTSD and
symptoms of common mental disorder. In
spite of the high levels of combat exposure,
death, and severe injury experienced over recent years by UK troops in Afghanistan, we
found no evidence to suggest that the mental
health of the deployed force was substantially different from that found in non-deployed
58
Leadership, Cohesion, Morale, and Mental Health of Armed Forces
samples. The distribution of mental health
cases was not uniform, and it varied with
the frequency of combat exposure. We found
there to be a strong effect for cohesion, good
leadership, and morale on mental health
overall and that the best primary prevention
of mental disorders, particularly PTSD, depends on the promotion of cohesion, good
leadership, and morale, not on specific psychological interventions.
REFERENCES
Brailey, K., Vasterling, J., Proctor, S., Constans,
J., & Friedman, M. (2007). PTSD symptoms,
life events, and unit cohesion in U.S. soldiers:
Baseline findings from the neuro-cognition deployment study. Journal of Traumatic Stress,
20, 495-503.
Decoufle, P., Holmgreen, P., Boyle, C.A., &
Stroup, N.E. (1992). Self-reported health status of Vietnam veterans in relation to perceived
exposure to herbicides and combat. American
Journal of Epidemiology, 135, 312-323.
Defence Analytical Services and Advice. (2010).
UK Operational Morbidity Reports. British
Casualties – Afghanistan Edition, 07 October
01–15 October 10. Retrieved November 8,
2010 from www.dasa.mod.uk.
Fear, N.T., Jones, M., Murphy, D., Hull, L.,
Iversen, A., Coker, B., et al. (2010). What are
the consequences of deployment to Iraq and
Afghanistan on the mental health of the UK
Armed Forces? Lancet, 375, 1783-1797.
Fear, N.T., Seddon, R., Mulligan, K., Wessely,
S., Jones, N., & Greenberg, N. (submitted for
publication). Does anonymity increase the likelihood of participants reporting mental health
symptoms? British Journal of Psychiatry.
Forbes, D., Creamer, M., & Biddle, D. (2001).
The validity of the PTSD checklist as a measure of symptomatic change in combat related
PTSD. Behaviour Research and Therapy, 39,
977-986.
Goldberg, D.P., Gater, R., Sartorius, N., et al.
(1997). The validity of two versions of the
GHQ in the WHO study of mental illness in
general health care. Psychological Medicine,
27, 191-197.
Gould, M., Adler, A., Zamorski, M., Castro, C.,
Hanily, N., Steele, N., et al. (2010). Do stigma
and other perceived barriers to mental health
care differ across armed forces? Journal of the
Royal Society of Medicine, 103, 148-156.
Grinker, R.R., & Spiegel, J.P. (1963). Men under stress. War neuroses among combat fliers.
New York: McGraw Hill.
Hoge, C.W., Castro, C.A., Messer, S.C.,
McGurk, D., Cotting, D.I., & Koffman, R.L.
(2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to
care. New England Journal of Medicine, 351,
13-22.
Hotopf, M., Hull, L., Fear, N.T., Browne, T.,
Horn, O., Iversen, A., et al. (2006). The health
of UK military personnel who deployed to the
2003 Iraq war: A cohort study. Lancet, 367,
1731-1741.
Jenkins, R., Meltzer, H., Bebbington, P.,
Brugha, T., Farrell, M., McManus, S., & Singleton, N. (2009). The British Mental Health
Survey Programme: Achievements and latest
findings. Social Psychiatry and Epidemiology,
44, 899-904.
Jones, N., Fear, N.T., Jones, M., Wessely, S.,
& Greenberg, N. (2010). Long-term military
work outcomes in soldiers who become mental
health casualties when deployed on operations.
Psychiatry, 73(4), 352-364.
King, A. (2006). The word of command. Armed
Forces and Society, 32, 493-512.
Lazarus, R. (1991). Psychological stress in the
workplace. In P.L. Perrewe (Ed.), Handbook on
job stress (pp. 1-13). Corte Madera, CA: Select
Press.
McLay, R., Deal, W., Murphy, J., Center, K.,
Kolkow, T., & Grieger, T. (2008). On-the-record screenings versus anonymous surveys in
Jones et al.
reporting PTSD. American Journal of Psychiatry, 165, 775.
McManus, S., Meltzer, H., Brugha, T., Bebbington, P., & Jenkins, R. (2009). Adult psychiatric morbidity in England, 2007: Results
of a household survey. Leeds: NHS Information Centre for health and social care, 2009.
Retrieved November 8, 2010 from http://signposting.ic.nhs.uk/?k=Adult+psychiatric+morbi
dity+in+England%2C+2007%3A+results+of+
a+household+survey
Mental Stress Training Is Planned for U.S. Soldiers. (2009, August 18). New York Times, p.
A1.
Mulligan, K., Fear, N.T., Jones, N., Wessely, S.,
& Greenberg, N. (2010). Psycho-educational
interventions designed to prevent deploymentrelated psychological ill health in Armed Forces
personnel: A review. Psychological Medicine,
41, 673-686.
Mulligan, K., Jones, N., Woodhead, C., Davies,
M., Wessely, S., & Greenberg, N. (2010). Mental health of UK military personnel while on
deployment in Iraq: The Operational Mental
Health Needs Evaluation (OMHNE). British
Journal of Psychiatry, 197, 405-410.
Office of the Command Surgeon US Forces
Afghanistan (USFOR-A) and Office of the
Surgeon General United States Army Medical Command. (2009). A report detailing the
findings and recommendations of the Mental
Health Advisory Team (MHAT) 6. Operation
59
Enduring Freedom 2009 Afghanistan. Retrieved November 8, 2010 from http://www.
armymedicine.army.mil/reports/mhat/mhat_vi/
MHAT_VI-OEF_EXSUM.pdf.
Pietrzak, R.H., Johnson, D.C., Goldstein,
M.B., Malley, J.C., & Southwick, S.M. (2009).
Psychological resilience and postdeployment
social support protect against traumatic stress
and depressive symptoms in soldiers returning from operations Enduring Freedom and
Iraqi Freedom. Depression and Anxiety, 26(8),
745-751.
Sharpley, J.G., Fear, N.T., Greenberg, N., Jones,
M., & Wessely, S. (2008). Pre-deployment stress
briefing: Does it have an effect? Occupational
Medicine, 58, 30-34.
Sijbrandij, M., Olff, M., Reitsma, J.B., Carlier,
I.V.E., & Gersons, B.P.R. (2006). Emotional
or educational debriefing after psychological
trauma: Randomised controlled trial. British
Journal of Psychiatry, 189, 150-155.
Updegraff, J., Silver, R., & Holman, A. (2008).
Searching for and finding meaning in collective trauma: Results from a national longitudinal study from 9/11 terrorist attacks. Journal of Personality and Social Psychology, 95,
709-722.
Weathers, F., Litz, B., Herman, D., Huska, J.,
& Keane, T. (1994). The PTSD checklist – civilian version (PCL-C). Boston: National Center
for PTSD.